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o V C! 2 APPLICATION FOR P R.°'.IT <br /> IrdSAN 0A6CiI: LOCAL HEALTH 'DISTRICT PERMIT NO. �� Z <br /> APR1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 DATE ISSUED 41— k <br /> SAN JOAQUIN . CAL PERMIT EXPIRES I YEAR FROM 04TE ISSUED <br /> HEALTH DISTRICT (Complete in Triplicate) <br /> rein <br /> Application is hereby made otoithe <br /> San <br /> s made iJoaquin <br /> Local <br /> wHealth th District <br /> for <br /> a permit <br /> toeconsto. ruucct an sewageSoriNoth1862rfor ewell/pump <br /> described. This application <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Subdivision Name <br /> Job Address Z. - Phone <br /> �tldress �ZU <br /> Owner's Name ® Phone <br /> Contractor's Name <br /> , n License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ID OTHER <br /> REPLACEMENT DESTRUCTION 71 <br /> OTHER <br /> D <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ DISPOSAL SEWER LINES FLD. ?ROY. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � • OTHER WELL PITS/SUMPS <br /> .�. FOUNDATION <br /> . ^ <br /> r AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL 1 PRO <br /> EM AREA <br /> { Dia. of Well Excavation <br /> "` t-'" ` <br /> "-Open•liottcm Q'MarFtl?ca <br /> Industrial• P <br /> i Domestic/Private EJGravel Pack F-1Tracy Dia. of Well Casing V' <br /> .1 <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑Eastern Specifications N <br /> ❑ <br /> Depth Depth of Grout Seal <br /> Cathodic Protection <br /> ❑ Type of Grout <br /> Geophysical rn <br /> ❑Other Surface Seal Installed by r <br /> T <br /> T of Pump _ H P State Work Done <br /> Repair Work Done Type <br /> Sealing MaterialE(top 50' <br /> Well Destruction ❑) Well Diameter <br /> } <br /> Depth Filler Material '(Below 50') <br /> REPAIR/ADDITION Q(No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [] J available within 200 feet.) <br /> 4 <br /> ...Commercial Other <br /> Installation;�wi31 serve:' Residence Lot size <br /> Number of bedrooms <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: i Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg I CapatI y '� _`'1, Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg - T .property Line <br /> Foundation E <br /> SEWAGE SYSTEM ❑ Distance'to nearest: Well »; <br /> DESTRUCTION ' <br /> ❑ Total length/size,, r <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED Foundation Property LineY <br /> ❑ Distance to nearest; Well p <br /> Depth __�.�� Size Number <br /> SEEPAGE PITS ❑ Foundation Property Line <br /> SUMPS ❑� -Distance to nearest: Well d <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have <br /> rprepared <br /> d this <br /> reguatPonsaofoth e SanhJoaquenwLocal ork �Heall lthdDistrone nctccordance with San Joaquin county <br /> ordork <br /> inances, f g% at 111 <br /> Home owner or licensed agent's signature certifies <br /> such manner to become subjectntohworkman compensatnce bf. hionwlawsof California." <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring'or sub-contracting ersonsusubjectcertifies <br /> workma eslcompensationncertify <br /> laws ofthat <br /> Californiaerformanceho the work for which <br /> this permit is issued, I shall employ p reV�rse side:' i^��_^ —__ <br /> The applitan in t c 11 for <br /> re wed inspections' Complete dra g on. y Date: <br /> „Title:. �. I <br /> Signed X r <br /> FOR DEPAR NT U ONLY 1 Area ❑ Stk 466-6781 <br /> Application Accepted b ❑ Lodi 369-3621 <br /> Additional Comments: Date {'Manteca 823-7104 <br /> Pit or Grout Inspection by Date ✓❑Tracy 835-6385 <br /> E Final Inspection by <br /> P,O. Box 2009, 5t k., CA 9j201 <br /> P J <br /> Applicant - Return all copies o: Environmental Healtfi: Permit/Services 1601 E. Hazelton Ave_ I � <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED 8Y DATE PERMIT NO. <br /> T - <br /> INFO <br /> 1 �z:&F <br /> ` .� 10/82 500 <br /> - `"`4_(d'—P4 - CA11 <br /> EH 13-24 REV. 10182 -7© y h� �vwlr L° <br /> 14-26 <br />